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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br />�i <br /> Application is hereby made_to-carry on business in the j rlsdictional area of the Sa Joain Loca�l-y,,�alth Dist ict <br />{ w Business/N—ame (DBA) J /'nt�et�7iC r6iuk 06. 2h C Address /".0 • L1 a,� 7�7 <br /> aOwner &nnP$f Q 4a bPf^Cy Address tS/4M <br /> Y Firm Partners, Addresses and Telephone Numbers <br /> f a Business Telephone No. Emergency Telephone No. <br /> I Contractor Licence No. �. Z <br /> � <br /> Appli11 cants Name (Print) Title Dale 1 <br /> Please check Applicable Category (1-7) and Fill in th equired Information -j <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, a June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. t <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑-PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. RKANITATION PERMIT <br /> Job Addresrs/Lo ation U r' Owner i,'J" �������I t' Address iM <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD @-'SEEPAGE PIT ❑ PACKAGE PLANT I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW M-9-EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> i Plant Location <br /> f Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k ,r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ruand regulati of t San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> i <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH =. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT - <br />€ <br /> FEEI <br /> E LESS F <br /> E PRORATION a ° AN <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Received by- Date Receipt No.> Permit No. - Issliance Dafte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITl$ERVICES •1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 65201 <br />